Healthcare Provider Details

I. General information

NPI: 1043857105
Provider Name (Legal Business Name): REAGAN RAVANZO BLANCO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2019
Last Update Date: 12/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4855 SW WESTERN AVE
BEAVERTON OR
97005-3460
US

IV. Provider business mailing address

1771 SE DOWERY LN
HILLSBORO OR
97123-5090
US

V. Phone/Fax

Practice location:
  • Phone: 503-813-2000
  • Fax:
Mailing address:
  • Phone: 971-227-8773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number122012
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: